Hoi t v khun chm xng i

chn on, iu tr?

Hoi t v khun chm xng i (HTVKCX) hay cn gi l hoi t v mch (Avascular
Necrosis) chm xng i l bnh c tn thng hoi t t bo xng v ty xng do thiu
mu nui trn chm xng i. Vng hoi t lc u to ra cc vng tha xng, cc khuyt
xng, v sau dn n gy xng di sn, cui cng gy xp chm xng i, thoi ha th
pht v mt chc nng ca khp hng, dn n tn ph.
Hoi t chm xng i nguyn pht thng gp tr em. Nguyn nhn thng khng r rng,
c th c hoc khng c yu t chn thng.
Hoi t chm xng i t pht thng gp nht tui trung nin (20-50 tui), nam thng
gp nhiu hn n (nam chim 80%). Ngoi ra HTVKCX cn xut hin th pht sau chn
thng v mt s nguyn nhn khc v ph thuc vo tui mc cc bnh l nn.
I. Nguyn nhn
1.1. Nguyn nhn nguyn pht. Thng gp nht, chim khong 50% cc trng hp.
1.2. Nguyn nhn th pht.
Do chn thng: do trt khp hoc gy c xng i. Thng thng hoi t xut hin sau chn
thng khong vi nm v khng nh hng nhiu n tui v gii.
Khng do chn thng: lm dng ru bia, thuc l, dng corticoid liu cao (thuc chng
vim), bnh kh p (th ln, cng nhn hm m), bnh hng cu li lim, bnh t min (lupus
ban , vim khp dng thp), ghp tng, vim rut, bnh l tng ng v bnh tc mch t pht,
i tho ng, ri lon chuyn ha m, thai nghntrong ru v corticoid chim khong
2/3 nguyn nhn gy hoi t chm xng i khng do chn thng.
II. Sinh l bnh
Khi mch nui dng b gim hoc tc nghn s gy ra cc vng nhi mu, nu nh v khng
din khp th vng nhi mu khng th hin triu chng lm sng, nu vng nhi mu ln v
gn din khp vng t th triu chng lm sng r. Trong vng 6h cc t bo m, tu xng
cng nh cc t bo xng s b cht. Vng hoi t st vi vng mch nguyn vn v cc t bo
cn sng tri qua qu trnh tiu hu xng cht v hnh thnh xng mi nhng tiu hu xng
thng din ra nhanh hn lm yu cu trc xng, gy ra gy cc b xng di sn, trn
Xquang gy ra du hiu hnh lim trc khi gy bt din khp, sau l gy mt khp. Qu
trnh ny khng th o ngc, ph hu khp v th hin cc triu chng trn lm sng.
Qu trnh hoi t ban u ch nh hng n xng chm xng i. Sn chm xng i vn
cn nguyn vn ti khi gy cc b xng do cn c nui dng bi dch khp v khng ph
thuc vo ngun mch nui dng trong chm xng i. Sau khi sp chm, sn khp phi chu
lc t c hc bt thng v dn ti thoi ho tin trin. Mt chm xng i khng u truyn
cc lc t bt thng ln sn ci v cng dn n thoi ho. Ti thi im ny, khng thy bin

i ci trn X quang nhng thy trn vi th v i th khi thay khp. Thoi ho tin trin
dn n hp khe khp trn X quang, x ho, hnh thnh khuyt xng v osteophyte.
III. Triu chng lm sng:
tr em triu chng thng khng r rng. au vng khp hng mt hoch hai bn. au c th
xut hin sau chn thng hoc khng c yu t chn thng. Thm ch, c trng hp bnh
nhn au, mi khp gi cng bn. Dng i lch v bn au. Giai on sau thy dng i tp
tnh, chn au ngn hn bn lnh.
ngi ln: Thng tn c th mt hoc hai bn khp hng, khong 70% cc trng hp tn
thng xut hin mt bn. giai on sm thng bnh nhn khng c triu chng g c bit.
Giai on mun hn, triu chng chnh l au khp hng bn tn thng. au thng xut hin
t t, tng dn, au tng ln khi i li hoc ng lu, gim khi ngh ngi. Bnh nhn thng
khng c cc biu hin ton thn nh sttr cc triu chng ca bnh nn nu c (lupus ban
).
Khm thy: giai on sm, vn ng khp hng khng hn ch, mun c biu hin hn ch bin
vn ng khp hng nh bnh nhn ngi xm kh khn hoc khng ngi c, bnh nhn
khng xoay hoc dng khp hng bnh thng c, trong khi gp dui gn nh bnh thng.
Giai on mun khp hng hn ch vn ng tt c cc ng tc.
Ngoi ra cn khai thc tin s nghin thuc, ru, dng corticoid liu cao, chn thng khp
hng hoc cc bnh l phi hp khc khi bnh nhn c du hiu nghi ng.
IV. Cn lm sng
Xt nghim: Cc xt nghim sinh ha, huyt hc bnh thng
Trn phim Xquang thng qui: thng ch pht hin c khi bnh giai on mun. Cc hnh
nh thng thy l xp chm t mc nh n nng, nng nht chm b tiu mt phn hoc
hon ton, hp khe khp. Ngoi ra c nhng bin i cu trc xng nh mt cht khong kh
tr, v xng di sn.
Trn phim CT-scaner: khng th pht hin sm nhng bt thng ty v mch mu ca chm
trong hoi t v khun. Du hiu sm nht c th pht hin c trn phim CT l tha xng.
Cc du hiu khc gm cc nt tng t trng khng u hoc nhng gii tng t trng vi b dy
khc nhau; ng sang di sn; v xng di sn v bin dng chm.
Trn phim cng hng t (MRI): MRI l phng tin chn on hnh nh c kh nng pht
hin sm nht nhy nht HTVKCX. Tn thng trn MRI gm hnh nh vng gim tn hiu
chm xng i pha ngoi v tng tn hiu pha trong.

Hnh nh X quang ca mt bnh nhn 7 tui b tiu chm xng i tri.

V. Chn on giai on
Theo Ficat v Arlet (1997) c 4 da trn biu hin phim Xquang ca chm xng i (nm
1985 m rng thm giai on 0).
0: ch pht hin da trn sinh thit
1: Xquang bnh thng, chn on da vo CT-scanner, MRI.
2: X.quang bt thng, cha c xp chm.
2a: c xng hnh dng a dng, km hc sng.
2b: Du hiu gy xng di sn, biu hin ng sng hnh lim.
3: Xp chm xng i, v xng di sn.
4: Thoi ha khp th pht, bin dng chm xng i.
Vi s ra i ca CT v MRI, nm 1993, ARCO (Association Reseach Circulation Osseous )
xut chia ra lm 6 giai on (hay 6 ) v h thng phn loi ny hin ang c s dng ph
bin nht.
0: Ngi c yu t nguy c hoi t chm xng i khng chn on c trn X quang qui
c, CT scan, MRI. Giai on ny tn thng qu nh khng th pht hin bng cc k thut
khoa hc hin ti hay cn gi l khong trng ca bnh.
1: H hi mch mu xy ra, X quang qui c cha pht hin bt thng nhng CT, MRI pht
hin c bt thng, bnh nhn bt u phn nn au m khng lin tc vng hng b tn
thng, cng c th au khp gi.
2: X quang qui c cho thy r c vng thu quang v vng x cng m t s sa cha
ca qu trnh nhi mu, x hnh xng, CT, MRI cho php chn on (+). Giai on ny tng
ng vi qu trnh tiu xng v nhi mu xng. Bnh nhn thy au khi i li v gim au khi
ngh ngi.
3: giai on ny biu hin ni bt l s gy xng di mt sn, biu hin l hnh nh
thu quang hnh trng li lim xut hin di mt sn, chm xng i vn cn nguyn vn
khng b bp. Hnh nh trng li lim ny l du hiu ca xp xng xp di mt sn, mt sn
vn cn nguyn vn. giai on ny cn c chia ra lm 3 mc : A ( nh: 30%)
4: Mt sn b xp v s nng di sn yu i. i khi s bp ca chm xng i l qu
nh pht hin trn x quang qui c thng nghing, tuy nhin CT, MRI th thy rt r. giai
on ny ci vn cn nguyn vn.
5: ci b nh hng bi s kch thch ca khng hp nhau vi chm xng i, iu
c th hin l khe khp hp li v c s x cng c ci v chm xng i. phn ra c
cc chi xng do bin dng ca chm xng i lm cho bnh nhn phi chu ng au n
lin min. Khp hng bt u khng th cu vn c.
6: ging nh 1 vim xng khp tin trin, khe khp bin mt, chm xng i v, mt sn
khp bin mt. Chm xng i hoi t v vn, bnh nhn phi chu au n lin tc, i li
gim nghim trng.
VI. Chn on phn bit
Giai on sm: cn phn bit vi cc bnh nh vim hoc u mng hot dch, vim sn khp v
cc vim khp do nguyn nhn khc.
Giai on mun: cn phn bit vi lao khp, vim ct sng dnh khp, vim khp do vi khun.
vim khp dng thp

VII. iu tr
Nguyn tc: ph thuc vo giai on tin trin ca bnh giai on chn on v cc yu t
khc nh tui, mc tn thng v cc yu t nguy c i km.
Phng php iu tr: theo 2 giai on
Giai on sm: vi mc tiu iu tr l d phng v hn ch ti a tin trin nng ln. Phng
php thng dng l khoan gim p. tr em, s dng np chnh hnh c t ngi vi mc ch
lm gim t nn trn chi tn thng gip lm gim nguy c bin dng chm, trt khp hng.
Giai on mun: khi chm xng i bin dng hoc tiu chm, khi ch nh phu thut
thay khp hng bn phn hoc ton phn c t ra.
iu tr c th:
Cc bin php khng dng thuc:
Loi b cc yu t nguy c: b thuc l, trnh ru bia, trnh hoc hn ch ti a s dng
corticoid
Gim ti ln chn au: gim hot ng hoc dng nng tr khi i li
Tp vn ng khp, trnh bin chng co khp
Kch thch in
iu tr bng thuc: s dng cc thuc chng vim khng steroid phi hp thuc gim au
thong thng, b sung can xi. iu tr cc bnh l phi hp.
iu tr phu thut:
Khoan gim p: khi tn thng 1 v 2 (theo ARCO).
Ghp xng: khoan gim p km ghp xng c cung hoc t do khi HTVKCX 3
c xng sa trc (Osteotomy): chnh trc u trn xng i nhm thay i t nn trn
chm.
Thay khp hng nhn to: l mt gii php vi nhng trng hp hoi t v khun chm
xng i giai on mun ( 3 v 4 theo Ficat), chc nng khp hng b tn thng nghim
trng, gip ngi bnh gim v ht au, ci thin chc nng khp hng. Bnh nhn c th i li,
lao ng gn nh bnh thng.
Kt lun:
HTVKXC khi pht lc u m thm v l hu qu ca thi cn tr. Nu c pht him sm
s dng np chnh hnh gip gim nguy c bin dng chm v trt khp hng. Khi bnh nhn
xut hin triu chng th tn thng hoi t tin trin mc nhanh n thi im can thip
phu thut l cn thit.
Vic pht hin sm v iu tr kp thi, c bit giai on cu trc gii phu ca chm xng
i cn nguyn vn l l tng v d sao, mt khp hng tht vn tt hn l s dng khp hng
nhn to.
Vic d phng HTVKCX i hi phi loi b cc yu t nguy c, trong bn cnh cc yu t
bnh ngh nghip l cc yu t nguy c khc c th loi b c l ru v thuc l.